<!-- edit-contact-information -->

<link rel="stylesheet" type="text/css" href="css/bootstrap.css">

<div id="dialog-fade"  id="sales-profile" tabindex="-1" role="dialog" style="width: 600px;">
<div id="dialog-bg" style="height: 400px;">
       <div id="modal-header">Edit Contact Information</div>
           <div id="modal-body">
           		  <div class="modal-content" style="height: 300px; width: 580px;">
           		<form name="editPhoneContactInformation">
						<div class="">
							<fieldset class="qr">
								<legend>Address, Phone and Email</legend>
							
							<table style="width: 100%;">
								<colgroup>
									<col style="width: 20%;">
									<col style="width: 20%;">
									<col style="width: 20%;">
									<col style="width: 40%;">
								</colgroup>
								<tr>
									<td style="padding-top: 6px;" colspan="3"><span
									class="fieldLabel">Country of residence</span><br/>
									<select><option value="">Select....</select></td>
								</tr>
								<tr>
									<td style="padding-top: 6px;" colspan="3"><span
									class="fieldLabel">Residential Address</span><span class="requiredFieldIndicator">*</span><br/>
									<input type="text" name="address1" placeholder="addressLine1" required style="margin-top: 4px; width: 40%;"><br/>
									<input type="text" name="address2" placeholder="addressLine2" required style="margin-top: 4px; width: 40%;">
									</td>
								</tr>
								<tr>
									<td style="padding-top: 6px;" colspan=""><span
									class="fieldLabel">City</span><span class="requiredFieldIndicator">*</span><br/>
									<input type="text" name="city" required style="margin-top: 4px; width: 40%;">
									</td>
									<td style="padding-top: 6px;" colspan=""><span
									class="fieldLabel">State/US Territory</span><span class="requiredFieldIndicator">*</span><br/>
									<select name="state" required><option value="">Select....</select>
									</td>
									<td style="padding-top: 6px;" colspan=""><span
									class="fieldLabel">Zip Code</span><span class="requiredFieldIndicator">*</span><br/>
									<input id="zipcode5" name="zip-code5" maxlength="5" size="5" required>-<input id="zipcode4" name="zip-code4" 
									maxlength="4" size="4" required>
									</td>
								</tr>
							</table>
							</fieldset>
						<br/>
							<table style="width: 100%;" class="">
								<colgroup>
									<col style="width: 70%;"/>
									<col style="width: 10%;" style="horizontal-align: middle;"/>
									<col style="width: 20%;"/>
								</colgroup>
								<tr>
									<td class="commentHeader">Phone Numbers<span class="requiredFieldIndicator">*</span>
									<span class="commentHeader">(Limit One Phone per Type)</span></td>
									<td class="commentHeader">Best#</td>
									<td class="commentHeader">&nbsp;</td>
								</tr>
								<tbody>
									<tr>
										<td>
											<table width="100%">
												<tr>
													<td width="20%"><select name="phoneType" required><option value="">
													Select....</option>
													<option value="">Cell</option>
													<option value="">Home</option>
													<option value="">Work</option>
													<option value="">Fax</option>
													<option value="">International</option></select>
													</td>
													<td width="30%"><input type="text" value="" maxlength="10"></td>
													<td width="30%">&nbsp;</td>
													<td width="18%"><span>ext.<input type="text" value="" size="4" maxlength="4"></span></td>
													<td width="2%"></td>
												</tr>
											</table>
										</td>
										<td><input type="radio" value=""></td>
										<td>
											<table>
												<tr>
													<td width="40%"><span><a href="">Delete</a></span></td>
													<td width="40%"><span><a href="#">Add Phone</a></span></td>
												</tr>
											</table>
										</td>
									</tr>
									<tr style="background: #FFFFFF">
										<td></td>
										<td colspan="2"><span>@@@ is the <span class="fieldLabel"> Best#</span> to call</span></td>
									</tr>
								</tbody>
							</table>
							<table width="100%">
								<tr>
									<td style="padding-top: 6px;" colspan="2"><span class="fieldLabel">Email Address</span><br/>
									<input type="email" name="email" maxlength="60" style="width: 30%;"></td>
								</tr>
							</table>
						</div>
						
					</form>
					</div>
					<div id="dialog-buttons" style="text-align: center;">
							<button type="button" class="medium green button" onclick="submit">Submit</button>
							<button type="button" class="button secondary" data-dismiss="modal">Cancel</button>
					</div>
					</div>
				</div>
			</div>
